Inspection Reports for
Cedarhurst of Springfield

The investigation was triggered by a complaint about staff failing to monitor and investigate bruising on Resident #1. The complaint was substantiated as the facility did not document or report new bruises and failed to investigate the cause.

The facility failed to monitor and investigate unusual and suspicious bruising on a resident, and staff did not document or report new bruises appropriately. The Director of Nursing and Executive Director were responsible for the investigation but did not ensure proper documentation or follow-up.

The complaint investigation substantiated abuse involving staff manually restraining Resident #1, dragging the resident in a chair, and holding the resident's room door closed to prevent exit. The investigation determined the violation was at an imminent danger Class I level. Staff involved were suspended and corrective actions were implemented.

The facility failed to ensure a resident was free from abuse when staff manually restrained the resident and prevented the resident from leaving the room. The investigation found evidence of physical and mental abuse, including restraining the resident in a chair and holding the room door shut. The facility implemented corrective actions and training to address these issues.

The facility failed to provide 24-hour protective oversight for one resident who left the secured building on two occasions without staff knowledge. Additionally, the facility failed to obtain a physician order for antibiotic ointment for another resident with a skin tear.

The facility failed to update the Community Based Assessment for a resident with a significant change in condition and did not complete monthly summaries of residents' conditions and medication reviews as required.

The facility failed to ensure clear and consistent documentation of a resident's code status, resulting in staff not initiating CPR when the resident was found without pulse or respirations. The resident's medical records contained conflicting information regarding resuscitation preferences and the facility did not follow its own policies for non-responsive residents.

The facility failed to maintain the sprinkler system according to NFPA 25, 1998 edition, as there was no documentation of a required five-year internal pipe inspection. The facility had sixty-two residents at the time of inspection.

The complaint investigation found that staff did not document notification of the physician orders to the resident's responsible contact person or in the resident's nurse notes. The issue was substantiated based on interviews and record review.

The facility failed to document notification of the physician and responsible contact person for Resident #1 when staff identified two skin abscesses. The resident's medical records and nurse notes showed incomplete documentation of physician orders and notifications related to the resident's skin condition.

The facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. The administrator was unaware of the requirement for a semiannual fire alarm inspection.